The mother was frantic.
 
“I don’t know what happened” she cried to the Paediatrician, “he was just a bit irritable when I put him to sleep last night and had a bit of redness around his mouth, but this morning his skin is falling off!” She then dissolved into floods of tears.
 
The Paediatrician took one look at the blisters and broken skin around the baby’s umbilicus and nappy area and asked “could he have been scalded with hot water at all? He looks burnt!

“Can I discuss an unwell baby?” asked the Neonatal Registrar.
 
“Of course, what’s the story?” replied the Microbiologist.
 
“We have a baby who is just over 24 hours old. They were born at term in good condition but started to grunt and looked mottled by 4 hours. We brought them to the Neonatal Unit, did blood cultures and started IV Benzylpenicillin and Gentamicin as per guidelines but they’re not really improving. Do you think we need to change the antibiotics? Has anything grown in the blood culture?”
 
The Microbiologist chose to ignore the last question as blood cultures are incubated in an automated incubator which scans the bottles every 10 minutes. If the blood culture where positive then it would have been phoned already.
 
“Is the baby’s mother okay? Have there been any problems during the pregnancy. Was the mother fully vaccinated? Was the labour normal? Is there anything else you’ve noticed about the baby, any odd lumps, bumps or spots?” asked the Microbiologist.

Hospital acquired infections are never a good thing, usually there is simply lapse in care, resources or common sense behind most occurrence. The normal kinds of infection you “expect” to see being acquired in hospitals are MRSA, Norovirus or Clostridium difficile. However sometimes outbreaks can be a real mystery to solve. I have had to deal with an unusual outbreak of hospital acquired fungal infection myself, so I was intrigued to “read on” when I saw this week’s headlines that “a strange outbreak had occurred in a Scottish hospital”.
 
This outbreak occurred at the Queen Elizabeth University Hospital in Glasgow and sadly patients have died as a result. An outbreak is defined when there are two or more cases linked in time, place or person. A single infection can constitute an outbreak if the infection is significantly rare or unlikely in the particular situation. The Glasgow outbreak is unusual in that it is not the normal kind of infection you expect to see being acquired in hospitals, this was cryptococcosis.
 
Cryptococcosis is a fungal infection caused by yeast like organisms of the family Cryptococcus spp. There are three main subspecies which infect humans:

• Cryptococcus neoformans var. neoformans
• Cryptococcus neoformans var. grubii
• Cryptococcus gatii

 
Cryptococcus spp. are found worldwide and throughout the environment; C. gatii is mainly found in the tropics whereas C. neoformans is more common and widespread. C. neoformans is principally found in pigeon droppings and pigeon nests as well as soil whereas C. gatii tends to be found in the bark of trees as well as soil. Other animals have been known to carry Cryptococcus spp. including cats, dogs, horses and even camels, llamas and alpacas!

​The Microbiologist was sat at his desk Boxing Day morning authorising out results and waiting for some further work on the blood cultures before ringing them out when his oncall mobile phone went off.
 
“Hi, it’s the ED Registrar here; can I discuss a patient with you?”
 
“Of course, what have you got” answered the Microbiologist.
 
“We’ve got a chap who has recently been abroad and has presented with a fever and feeling unwell. The basic story is that he returned home from work in the early hours of this morning looking flushed and tired. His wife was worried about him, as his belly was rather distended, so persuaded him to come to the hospital. He insists this is how he normally feels at this time of year but his wife isn’t convinced.”

The patient was a young man in his early 20s. He presented to the Emergency Department with pain in his neck and difficulty swallowing. He managed to tell the ED Doctor that he had had a bad toothache for over a week but had been putting off seeing a Dentist because “he had too many other things to do”.
 
On examination he was febrile and tachycardic and his respiratory rate was high. The ED Doctor could see that his neck was swollen even by looking from the end of the bed.

“I have a 3 year old patient with an infected ulcer on their leg which is proving particularly difficult to treat” was the opening statement from the Surgeon.
 
“What antibiotic are you giving?” asked the Microbiologist in a surly tone, thinking this was going to be a simple case of wrong antibiotic.
 
“I’ve been using Co-amoxiclav, but it doesn’t seem to be getting better” was the reply.
 
“Have you sent any samples to the lab?”
 
“I swabbed the wound and the result has come back showing a Coagulase-positive Staphylococcus; I wonder if this might be Staphylococcus pseudintermedius or possibly Staphylococcus aureus” said the Surgeon.
 
“Staphylococcus aureus is the most common bacterium we see in this situation” answered the Microbiologist, “why do you think it might be Staphylococcus pseudintermedius?”
 
“In our patients Staphylococcus pseudintermedius is often grown from these types of samples…oh, I forgot to mention, I’m a Veterinary Surgeon and the 3 year old patient is a Husky” was the reply…. “I should say too that the bacterium is resistant to beta-lactams… according to the report…

The phone started to vibrate at midnight and the Microbiologist groaned. Who would be ringing at the witching hour on Halloween? Then he started to worry… would it be safe to answer? Would there be some crazy person on the other end? Was it a vicious axe murderer? Then he remembered this was just the scary film he had watched before going to bed and he was actually on call for the hospital.
 
The person on the other end turned out to be the Emergency Department Registrar (certainly crazy for working Halloween in the ED…!)
 
“I’ve got a patient who has been bitten on their hand by a bat and I wondered what antibiotics we should start. We have guidelines for dog, cat and even human bites but nothing for bats.”

Looking down the blood cultures list whilst prioritising what needed phoning out first the Microbiologist noticed a blood culture positive on day 3 with a Gram-positive bacillus in the aerobic bottle only. Normally this wouldn’t provoke much interest as most pathogens grow within 12-24 hours and most Gram-positive bacilli are skin contaminants (Corynebacterium spp. and Cutibacterium spp.). However these were unlikely in this case: Corynebacterium spp. normally grow faster than this and would be in both bottles whereas Cutibacterium spp. although anaerobes tend to grow much slower. The clinical details just said “fever” (not overly helpful!) and considering the sample was 3 days old already, it didn’t seem that urgent, so the Microbiologist put it to the bottom of the list and got on busily calling out all of the Gram-negative bacilli and Gram-positive cocci, as these were more likely to be significant.

I am really fortunate to work with a great team of diagnostic cardiologists who have a keen interest in infective endocarditis. We have an endocarditis multidisciplinary team and do a ward round of all the endocarditis patients every week, regardless of where they reside in the hospital. One of the big problems for these patients is the long courses of IV antibiotics in the current treatment guidelines, be they British, American or European. As a result patients have long periods of time where they have central venous catheters (CVC) for administering the antibiotics and prolonged hospital stays; both predisposing to further infections.

​So when I saw an article in the New England Journal of Medicine from Denmark investigating whether oral antibiotics can be used in the treatment of this infection, my attention was stirred and I made the most of the present moment and ordered the paper from the library, “carpe diem”.

The patient was admitted 3 days after arriving in the UK from Nigeria. He had felt unwell with a fever and generalise aches and pains the day before he travelled. On the morning of admission he had noticed a rash on his left leg as well as tender enlarged lymph nodes in his groin.
 
The admitting Consultant Physician spoke to infection control before the patient arrived and it was decided to admit the patient directly to a negative pressure side-room in the infectious diseases unit without bringing the patient into the main hospital in case this might be a viral haemorrhagic fever. The patient met a diagnosis of low possibility of viral haemorrhagic fever; temperature ≥ 37.5 oC PLUS been in endemic area within 21 days of onset of illness.